MARYLAND STATE BOARD OF OCCUPATIONAL THERAPY

							                     MARYLAND BOARD OF OCCUPATIONAL THERAPY
                               SPRING GROVE HOSPITAL ● BENJAMIN RUSH BUILDING
                                 55 WADE AVENUE ● BALTIMORE, MARYLAND 21228
                              Phone 410-402-8560 ● Fax 410-402-8561 ● www.mdotboard.org

                                    CHANGE OF INFORMATION REQUEST
The law requires that Occupational Therapists and Occupational Therapy Assistants notify the Board in writing within 30
days of any change of address and/or name change. This is very important since the Board is required only to attempt to
contact you at the address we have on record.

The Board is authorized to proceed with its duties, including discipline, after it has attempted to contact you at the address
of record, with or without your participation. Failure to notify the Board of an address/name change may result in your
failure to receive a renewal application, which may in turn lead to disciplinary action for practicing on an expired license.

The Board must, by law, have a valid address/name for you. The address/name that you provide is the “address/name of
record” that is available for public information requests. Please provide a full mailing address and phone number at which
you can be reached during the day.

Untimely notification to the Board of an address/name change will result in a late fee of $50.

Name:                                                                        License Number:

                                                  Notice for Mailing Lists
The information collected is for the purposes of the Board’s functions under Annotated Code of Maryland 10.46.01.02.
You have a right to inspect, amend, and correct this information. The Board may permit inspection of this information or
make it available to others only as permitted by federal and State law. The Board may sell or provide a list of licensees’
names and addresses to professional associations and other entities. Under the Maryland Public Information Act, MD State
Government Code Ann. §10-617, you may request in writing that your name be omitted from such lists.

                              PLEASE DARKEN THE APPROPRIATE BOX
What information has changed?
 Name                    Home Address         E-mail Address  Home Phone                                            
Work Phone
                                        NAME CHANGE
Previous Name:                                       New Name:

If you are requesting a change of name, please submit a copy of a legal name change document, marriage certificate,
or divorce decree.
                                                  ADDRESS CHANGE
                  Old Mailing Address                                                  New Mailing Address
Street:                                                                  Street:
City:                                                                   City:
State:                              Zip:                                State:                          Zip:

                                                  PHONE NUMBER CHANGE
                   Home Number                                                                   Work Number
Old:                                                                         Old:
New:                                                                         New:

                                                 E-MAIL ADDRESS CHANGE
New E-mail Address:

I affirm that the contents of this document are true and correct to the best of my knowledge and belief. Further, I authorize
the Board to update their records to reflect this information.

Signature:                                                                           Date:

                                                           For Office Use:
Date Received:                                                               Date Processed:

D:\Docstoc\Working\pdf\7dc4405d-449d-47f6-92a2-6b0c8397797c.doc                  Rev 9/18/2007